A nurse is providing teaching to an assistive personnel (AP) about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?
Secure the client's restraints with a square knot
Attach the restraints to the fixed portion of the frame of the client's bed
Remove the client's restraints every 2 hours
Allow 1 fingerbreadth between the restraint and the client's wrists
The Correct Answer is B
A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.
B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.
C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.
D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Reminiscence therapy is a type of intervention that helps clients with Alzheimer's disease recall and share their past experiences, memories, and emotions. This can enhance their self-esteem, mood, and quality of life. By requesting a referral for this therapy, the nurse is advocating for the client's psychosocial needs and preferences.
Choice B reason: Performing an updated cognitive assessment on the client is not an example of advocacy, but rather a standard nursing practice. Cognitive assessments are used to monitor the client's cognitive status and progression of the disease. They do not necessarily reflect the client's wishes or interests.
Choice C reason: Providing assistance for the client when ambulating down the hall is not an example of advocacy, but rather a safety measure. The nurse is helping the client prevent falls and injuries, which are common risks for clients with Alzheimer's disease. This does not imply that the nurse is speaking up for the client or protecting their rights.
Choice D reason: Reorienting the client several times throughout the day is not an example of advocacy, but rather a therapeutic communication technique. The nurse is helping the client cope with confusion and disorientation, which are common symptoms of Alzheimer's disease. This does not indicate that the nurse is supporting the client's goals or values.
Correct Answer is B
Explanation
Choice A reason: The client's vital signs are not part of the background information, but rather the assessment information. The background information should include relevant and concise data about the client's history, diagnosis, and treatment.
Choice B reason: The client's name is part of the background information, as it identifies the client and establishes rapport. The name should be the first thing the nurse says when initiating the SBAR communication.
Choice C reason: The client's code status is not part of the background information, but rather the recommendation information. The code status should be communicated at the end of the SBAR communication, along with any other suggestions or requests for the receiving nurse.
Choice D reason: A prescribed consultation is not part of the background information, but rather the situation information. The situation information should describe the current problem or reason for the transfer.
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